Reducing drug harm

Practical advice to keep customers who use alcohol and drugs safe at all times.

However efficient the measures aimed at preventing drugs being brought into and sold at a venue are, many people see drug taking as integral to having a good time and it is a fact that significant numbers of people will take drugs before, during and/or after going to a club or festival.

Increasingly, many people “pre-load” both drugs and alcohol before going out, partly to circumvent security measures at premises or events. Owners, managers and promoters need to be aware that there is an expectation that they take responsibility for people affected by drugs (or other health issues) from the point that they join the queue to get in, through to ensuring that they are likely to get home safely.

This section covers the ways in which all agencies, but particularly venue owners and promoters, can protect the health and safety of their customers.

Nevertheless, the safest advice – don’t drink too much alcohol, don’t mix alcohol with drugs, don’t keep redosing or topping up – conflicts with what, for many people, are the essential elements of the night out.

This means that many people ignore the advice.

Alerts

Drug outreach services – where organisations provide drug information and advice at nightclubs and festivals – are no longer commonplace. Owners, managers and promoters can however fulfil a useful role in providing specific drug information about immediate concerns around a particular batch or type of pills or other substances being used at a club or festival.

An event’s medical and welfare team can spread the word about particular concerns and digital messages can also be sent via social media (using the hashtag for the event/festival) or via an app associated with the event and used for ticket purchases, event entry etc.

Access to information

It is also regarded as good practice for venues and festivals to advertise clearly information on how to contact on-site medical and welfare services and contact details for local services who can provide advice and support for customers who are concerned about their general level or patterns of drug taking.

Toilet and chill out areas are obvious places to post this information.

Drug testing

One of the main risks from illegal drug taking is that it is impossible to know exactly what substance you are taking.

Unlike legal medicines or alcohol, the contents of any particular pill or powder are likely to vary enormously. A tablet may or may not contain the chemical substance it is sold as containing and the dosage – and therefore how much it affects the body – is unknown.

Recent research1 Couchman L et al. (2019) Variability in content and dissolution profiles of MDMA tablets collected in the UK between 2001 and 2018 – a potential risk to users? Drug Test Anal. DOI:10.1002/dta.2605 https://www.ncbi.nlm.nih.gov/pubmed/31009168 analysed over 650 seized ecstasy tablets and established that tablets from the same batch can contain very different concentrations of MDMA.

In response to this situation, a number of festivals started hosting drug testing facilities on site. There are two main approaches to drug testing: publicly accessible drug safety testing (also known as “drug checking” or front of house testing) where festivalgoers can submit substances of concern for analysis to find out their contents and strength; and non-public testing (also known as “back of house” testing), where substances which are seized or found by the police or the organisation running the festival are tested.

One of the main risks from illegal drug taking is that it is impossible to know exactly what substance you are taking. Unlike legal medicines or alcohol, the contents of any particular pill or powder are likely to vary enormously. A tablet may or may not contain the chemical substance it is sold as containing and the dosage – and therefore how much it affects the body – is unknown.

Recent research1 Couchman L et al. (2019) Variability in content and dissolution profiles of MDMA tablets collected in the UK between 2001 and 2018 – a potential risk to users? Drug Test Anal. DOI:10.1002/dta.2605 https://www.ncbi.nlm.nih.gov/pubmed/31009168 analysed over 650 seized ecstasy tablets and established that tablets from the same batch can contain very different concentrations of MDMA.

In response to this situation, a number of festivals started hosting drug testing facilities on site. There are two main approaches to drug testing: publicly accessible drug safety testing (also known as “drug checking” or front of house testing) where festivalgoers can submit substances of concern for analysis to find out their contents and strength; and non-public testing (also known as “back of house” testing), where substances which are seized or found by the police or the organisation running the festival are tested.

The best known UK organisation in this field is The Loop, a non-profit social enterprise which provides drug safety testing, welfare and harm reduction services at festivals and which was established in 2013.

This is how it works. Festival goers can bring any substances of concern for testing and receive results as part of an individually tailored brief intervention by healthcare staff. Users put a dose – a pill or approximately 5 mg of powder – into a small plastic bag which they seal and post in a locked amnesty bin. Individuals receive a unique ID number and are asked to return about an hour later while the substance is tested on site. In that time, the Loop’s team of professional chemists conducts up to five different analyses to best identify the sample in their pop up lab.

A recent evaluation1 Fiona Measham (2019) Drug safety testing, disposals and dealing in an English field: Exploring the operational and behavioural outcomes of the UK’s first onsite ‘drug checking’ service. International Journal of Drug Policy, Volume 67, May 2019, Pages 102-107 of The Loop’s work makes for interesting reading. Tests revealed that nearly one in five samples (19.5%) were different from what they were sold as. The most interesting part of the evaluation records what people who used the testing service said they intended to do when they were told what was actually in their drugs. About one in five people chose to use the police approved disposal service. Two thirds of those who found out their drugs were not what they thought they were handed over further substances in their possession.

The team at The Loop also provided a number of people who tested substances with onward referral to local health services.

Indeed, perhaps the main benefit of drug checking services is to engage drug using festival goers in conversations about how to reduce the harms of taking illegal drugs. People discuss not only their drug-related issues and concerns during the consultation, but often also questions about interactions between illegal drugs and medications or the contraceptive pill, managing a serious medical condition such as MS, and other health concerns that they prefer not to discuss with their own GP.

The purpose of back of house testing is somewhat different to public drug checking.

Organisations like TICTAC Communications1TICTAC Communications Ltd. Has been a leading provider of drug identification and drug information to the criminal justice and healthcare sectors over the last 20 years, it is based in the medical school at St. George’s University of London. analyse drugs which have been seized by the police or festival organisers.

Preliminary documentation and analysis is carried out onsite and further more rigorous analysis is performed subsequently in a laboratory if necessary. The information from their analysis is used for three main purposes:

To provide festival organisers with information about what drugs are being used and in particular any concerns about specific substances so that festival goers can be advised about heightened risks.

To provide security staff and police with intelligence about the range of substances being brought into the festival.

To analyse national trends in drug use so that policy makers, commissioners and providers of services can be aware of the latest drugs and changes in which drugs are being sold or consumed.

Should your festival provide drug testing?

The number of drug-related deaths at festivals has increased in recent years; for example at least three teenagers died from drug-related causes while attending music festivals over the August Bank Holiday weekend in 2019.

Festival organisers are urged to consider including drug testing services in their arrangements, whether front or back of house. Festival organisers should discuss their plans with local police, licensing authorities and public health in advance.

Festivals and local police are also strongly encouraged to consider non-public drug testing since intelligence about the latest trends in drug use are an invaluable component of planning appropriate responses.

Some festivals employ both public drug checking and non-public drug testing services as part of their multi agency harm reduction partnership with complementary and integrated testing between the two organisations.

TICTAC Communications Ltd. Has been a leading provider of drug identification and drug information to the criminal justice and healthcare sectors over the last 20 years, it is based in the medical school at St. George’s University of London.

License holders should be clear about how they will respond to drug and alcohol induced problems.

These problems may be of a medical or psychological nature and the assistance provided should be swiftly and easily accessible. The scale and type of medical interventions available will vary according to the type and scale of event being run.

The following section explores some of the key issues but does not attempt to prescribe definitive levels of medical cover.

Dedicated team

Larger clubs or festivals should employ a dedicated medical/welfare team who have received drug-specific training. These may be in-house employees or bought in from a number of companies who provide specialised services to dance events and festivals. Again, it is important that these companies have a track record of working with drug induced problems. It should not be assumed that such reputable organisations as the Red Cross or St. John Ambulance Service necessarily possess the requisite experience. Even highly experienced and skilled NHS trained doctors, nurses and paramedics should not be expected to work in this setting without the supervision of a colleague with experience of working with drug-induced problems. A list of specialist drug medical providers can be found here.

Training

The training provided to such staff should include information about common drug induced problems, such as anxiety, paranoia, seizures, heart rate and blood pressure problems and elevated body temperature. These will vary depending on the pattern of drug use locally. Staff, who for the first time encounter clubbers who have used ketamine for example, may not recognise the symptoms of use. It is important that local drug agencies are used to keep staff up-to-date.

First Aiders

Smaller venues should ensure that sufficient employees are trained as First Aiders to ensure that a minimum of two such staff are present at all times during any event. It is advisable that all newly qualified First Aiders work with more experienced staff.
The venue should ensure that medical staff have regular training and ensure that staff are clear about lines of accountability for their work.

Briefing all staff

Medical/welfare staff should regularly brief door supervisors, bar staff and other club staff about common symptoms of drug induced distress to look out for. Bar staff should also have comprehensive server training to help them to deal appropriately with people who are intoxicated through alcohol, drugs or a combination of the two.

The provision of a separate quiet cool room/area is the single most useful facility to those providing the medical service. A great deal of work with users suffering the negative effects of drug use involves providing reassurance and support in a calm, cool environment. It is impossible to do this work on a crowded dance/venue floor. It is better for the sufferer, member of medical/welfare staff and other customers for care to be administered privately and discreetly. The room must be of sufficient size for the patient to be laid down.

Minimum essential medical equipment for such a room is:

One or more beds,

Glucose monitoring equipment,

Blood pressure monitors,

Drinking water,

Thermometer,

A clock or watch with a second hand (to take heart rates accurately).

A duty of care

On no account should anyone suffering from the ill effects of drug and/or alcohol use be thrown out of the premises or left alone unmonitored. This is because very serious health consequences can be missed. Even if a customer is assessed as not being in need of medical treatment, it is important that their friends are recruited to help them get home safely.

Perhaps the most important element of an effective drug welfare response is to establish a culture in which all members of staff are proactively looking out for customers in distress as a core part of their job and ensuring that they immediately notify medical/welfare staff.

A critical decision for medical/welfare staff is whether and when to call for an ambulance. This section provides authoritative guidance on this issue.

The Clinical Toxicology team at Guy’s and St Thomas’ NHS Foundation Trust, in partnership with a number of other agencies, as part of the European Drug Emergencies Network (Euro-DEN) have developed a set of guidelines advising club medics/staff when to call an ambulance to assess whether an individual needs to be taken to an Emergency Department for ongoing treatment. These emergency guidelines are reproduced in full here. A training package was developed for club medics/staff using these guidelines.

Implementation of these guidelines requires that club medics and staff are not only aware of the guidelines but are appropriately trained in the assessment of individuals with recreational drug toxicity. This training should be done on a regular basis with refresher courses for those who have previously attended. It is also important that the guidelines form a part of the standard induction for all new staff; this is particularly important for venues that use agency based rather than permanent staff.

The local ambulance service should be involved in the implementation of these guidelines to ensure that things go smoothly when an ambulance is called.

It is natural for both businesses and licensing professionals to focus on safety at the dance event.

However, clubbers are particularly vulnerable on the way home where there is no-one designated to look out for them. The main risks are:

Customers driving home intoxicated through drink or drugs.

Customers leaving the event in need of medical help because of their level of intoxication.

Customers leaving the event in an intoxicated state and vulnerable to accident, assaults or other crimes.

Drink/drug driving

The dangers and illegality of driving with excess alcohol in the body are well known. However, driving when intoxicated by controlled drugs is at least as dangerous, as is driving when exhausted or hungover. On 2 March 2015 Section 5A of the Road Traffic Act 1988 came into force. For the first time the law prescribed upper limits for the level of specific controlled drugs in a driver’s blood, in the same way as we have a drink drive limit. The first year’s evaluation1 Risk Solutions & Centre for Public Health at Liverpool John Moores University (2017) Evaluation of the new drug driving legislation, one year after its introduction – a report for Department of Transport. analysed data from 24 police forces on 4,292 preliminary drug screening tests and found that 54% were positive for either cannabis, cocaine, or both.

Although many customers will now travel home by public transport or Uber (or other app based minicab hire services), venues should be sure to post information on reputable local taxi services and provide information about night buses or late night tube services.

Intoxicated customers leaving

Door supervisors, medical/welfare staff and all other staff should be vigilant about the welfare of customers leaving who seem seriously intoxicated, particularly if they are on their own. Such customers should be approached and offered the chance to see a First Aider or contact a family member or friend to pick them up and ensure they get home safely. Staff should ensure that customers have collected their coats and are adequately dressed for the season, overheated clubbers going home on cold evenings without adequate clothing may be at risk of hypothermia.

Safeguarding customers

It is also considered best practice to be proactive in safeguarding customers from unwanted sexual attention and possible assault. The #MeToo movement has made all members of society more aware of the prevalence of sexual predation. Responsible venues have a policy where intoxicated women going home with a man or group of men are discreetly approached to make sure that her companions are already known to her and trusted individuals who will ensure she gets home safely and not unknown people who may be intending to rob or sexually assault her. Similar precautions should be taken with male customers, especially at premises which specifically cater for Men Who Have Sex with Men.

It is important to train staff to be able to respond to customers who are experiencing unwanted attention. One such initiative is the Ask for Angela campaign which encourages customers who feel unsafe or threatened to talk to a member of staff and “Ask for Angela”, a codeword understood by staff who will contact security on the customer’s behalf. Posters giving information about the scheme are displayed in the toilets.

Risk Solutions & Centre for Public Health at Liverpool John Moores University (2017) Evaluation of the new drug driving legislation, one year after its introduction – a report for Department of Transport.

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